Formulary Addendum as of July 1, 2020 · ID: 20480 Version: 12 QL=Quantity Limits Apply, ST=Step Therapy Applies, PA=Prior Authorization Applies, LA =Limited Access

Formulary Addendum as of July 1, 2020

Additions

Drug Name Tier Notes Effective Date

ABILIFY MYCITE TAB 10MG 5 ST QL (30 tabs per 30 days) 1/ 1/20






AYVAKIT TAB 100MG 5 PA QL (30 tabs per 30 days) 4/ 1/20



AZASITE SOL 1% 3 2/ 1/20

AZELEX CRE 20% 4 3/ 1/20

BIVIGAM INJ 10% 5 PA 5/ 1/20

BRUKINSA CAP 80MG 5 PA 3/ 1/20

BYETTA INJ 10MCG 3 ST QL (2.4 ml per 28 days) 2/ 1/20

BYETTA INJ 5MCG 3 ST QL (4.8 ml per 28 days) 2/ 1/20

CAPLYTA CAP 42MG 5 ST QL (30 caps per 30 days) 6/ 1/20

cefixime cap 400mg 2 1/ 1/20

cinacalcet tab 30mg 5 1/ 1/20



CIPRODEX SUS 0.3-0.1% 3 2/ 1/20

clovique cap 250mg 5 PA 6/ 1/20

codeine sulf tab 15mg 1 6/ 1/20

CORDRAN 80X3 TAPE 4MCG/CM 4 3/ 1/20

diazepam gel 10mg 2 4/ 1/20

diazepam gel 2.5mg 2 4/ 1/20

diazepam gel 20mg 2 4/ 1/20

diazoxide sus 50mg/ml 5 7/ 1/20

dotti dis 0.025mg 2 1/ 1/20

dotti dis 0.0375mg 2 1/ 1/20

July 1, 2020 - MetroPrRx, Diocese, COH, CWA ID: 20480 Version: 12

QL=Quantity Limits Apply, ST=Step Therapy Applies, PA=Prior Authorization Applies, LA =Limited Access

Additions


dotti dis 0.05mg 2 1/ 1/20

dotti dis 0.075mg 2 1/ 1/20

dotti dis 0.1mg 2 1/ 1/20

doxepin tab 3mg 2 QL (30 tabs per 30 days) 3/ 1/20

doxepin tab 6mg 2 QL (30 tabs per 30 days) 3/ 1/20

DRIZALMA SPRINKLE CSDR 20MG 4 QL (60 caps per 30 days) 3/ 1/20




DULERA AER 50-5MCG 3 QL (13 gm per 30 days) 7/ 1/20

DUREZOL EMU 0.05% 4 2/ 1/20

eluryng 0.015mg/24hr- 0.12mg/24hr 2 3/ 1/20

ENBREL MINI INJ 50MG/ml 5 PA 1/ 1/20

erlotinib tab 100mg 5 PA QL (30 tabs per 30 days) 1/ 1/20



ESBRIET TAB 267MG 5 PA 4/ 1/20

esomeprazole gra 10mg dr 2 QL (60 pack per 30 days) 6/ 1/20



etonogesterel/ethynyl estradiol ring

0.015mg/24hr- 0.12mg/24hr

2 3/ 1/20

everolimus tab 0.25mg 5 PA 6/ 1/20

everolimus tab 0.5 mg 5 PA 6/ 1/20


everolimus tab 2.5mg 5 PA QL (30 tabs per 30 days) 3/ 1/20

everolimus tab 5mg 5 PA QL (30 tabs per 30 days) 3/ 1/20

everolimus tab 7.5mg 5 PA QL (30 tabs per 30 days) 3/ 1/20

febuxostat tab 40mg 2 1/ 1/20

febuxostat tab 80mg 2 1/ 1/20

FENTANYL CIT TAB 100MCG 5 PA 1/ 1/20




Additions





FERRIPROX TAB 1000MG 5 PA 2/ 1/20

FLOVENT HFA AER 110MCG 3 QL (24 g per 30 days) 2/ 1/20

FLOVENT HFA AER 220MCG 3 QL (24 g per 30 days) 2/ 1/20

FLOVENT HFA AER 44MCG 3 QL (21.2 g per 30 days) 2/ 1/20

FLUOROPLEX CRE 1% 4 4/ 1/20

gavilyte-g sol

236g-2.97g-6.74g-5.86g-22.74g

1 3/ 1/20

haloperidol dec inj 50mg/ml 2 7/ 1/20

IBRANCE TAB 100MG 5 PA 6/ 1/20



icatibant inj 30mg/3ml 5 PA 1/ 1/20

INREBIC CAP 100MG 5 PA 1/ 1/20

isosorbide dinitrate tab 40mg 5 3/ 1/20

KALYDECO PAK 25MG 5 PA 1/ 1/20

ketodan foam 2% 2 2/ 1/20

ketoprofen cap 50mg 1 6/ 1/20

ketoprofen cap 75mg 1 6/ 1/20

KOSELUGO CAP 10MG 5 PA 7/ 1/20

KOSELUGO CAP 25MG 5 PA 7/ 1/20

loteprednol sus 0.5% 2 1/ 1/20

mesalamine er cap 0.375g 2 3/ 1/20

metformin sol 500/5ml 2 ST QL (765 ml per 30 days) 7/ 1/20

metoprolol tar tab 37.5mg 1 2/ 1/20

metoprolol tar tab 75mg 1 2/ 1/20

NAYZILAM SPR 5MG 5 5/ 1/20

NOVOLIN INJ FLEXPEN 3 6/ 1/20

NOVOLIN N INJ 100 UNIT 3 7/ 1/20

NOVOLIN R INJ 100 UNIT 3 7/ 1/20



Additions


NUBEQA TAB 300MG 5 PA 1/ 1/20

PEMAZYRE TAB 13.5MG 5 PA QL (30 tabs per 30 days) 7/ 1/20

PEMAZYRE TAB 4.5MG 5 PA QL (30 tabs per 30 days) 7/ 1/20

PEMAZYRE TAB 9MG 5 PA QL (30 tabs per 30 days) 7/ 1/20

penicillamine tab 250mg 5 4/ 1/20

pentamidine inh 300mg 2 PA 3/ 1/20

pentamidine inj 300mg 2 3/ 1/20

PIQRAY 200MG TAB 5 PA 1/ 1/20



PLAQUENIL TAB 200MG 4 6/ 1/20

posaconazole tab 100mg dr 5 2/ 1/20

pregabalin cap 100mg 2 QL (90 caps per 30 days) 1/ 1/20








pregabalin sol 20mg/ml 2 QL (900 ml per 30 days) 1/ 1/20

PROMACTA PAK 25MG 5 PA 7/ 1/20

pyrimethamine tab 25mg 5 PA 7/ 1/20

ramelteon tab 8mg 2 QL (30 tabs per 30 days) 1/ 1/20

ROZLYTREK CAP 100MG 5 PA 2/ 1/20

ROZLYTREK CAP 200MG 5 PA 2/ 1/20

scopolamine dis 1mg/3day 2 1/ 1/20

SECUADO DIS 3.8MG/24HR 5 PA QL (30 patches per 30 days) 5/ 1/20



SIKLOS TAB 1000MG 5 PA 1/ 1/20

SIKLOS TAB 100MG 4 PA 1/ 1/20



Additions


sildenafil sus 10mg/ml 5 PA 1/ 1/20

sotalol af tab 160mg 2 6/ 1/20

sotalol af tab 80mg 2 6/ 1/20

sucralfate sus 1g/10ml 2 3/ 1/20

TAZVERIK TAB 200MG 5 PA 5/ 1/20

TDVAX INJ 2-2 LF 3 7/ 1/20

testosterone cyp inj 200mg/ml 1 PA 2/ 1/20

tiadylt cap 120mg/24hr 1 5/ 1/20





tiadylt er cap 360mg/24hr 1 2/ 1/20

tovet foam 0.05% 2 2/ 1/20

TRAVATAN Z DRO 0.004% 4 2/ 1/20

travoprost dro 0.004% 2 3/ 1/20

TURALIO CAP 200MG 5 PA 1/ 1/20

VALTOCO LIQ 15MG 5 QL (10 devices per 30 days) 5/ 1/20

VALTOCO LIQ 20MG 5 QL (10 devices per 30 days) 5/ 1/20

VALTOCO SPR 10MG 5 QL (10 devices per 30 days) 5/ 1/20

VALTOCO SPR 5MG 5 QL (10 devices per 30 days) 5/ 1/20

vancomycin sol 250mg/5ml 2 2/ 1/20

VICTOZA INJ 18MG/3ml 3 ST QL (9 ml per 30 days) 2/ 1/20

XELJANZ XR TAB 22MG 5 PA 4/ 1/20

XPOVIO PAK 100MG 5 PA 1/ 1/20




ZYKADIA TAB 150MG 5 PA 1/ 1/20



Deletions

Affected Drug

Description

of Change

Reason for Change

Alternative Drug Tier Notes Effective

AFINITOR TAB

2.5MG

Deletion Available in generic.

Only generic is

covered.


AFINITOR TAB

5MG


Only generic is

covered.

everolimus tab 5mg 5 PA 3/ 1/20

AFINITOR TAB

7.5MG


Only generic is

covered.


ala-cort cre 2.5% Deletion CMS Mandated

Deletion

Please consult with

your doctor.

4/ 1/20

alendronate tab

40mg

Deletion CMS Mandated

Deletion

Please consult with

your doctor.

5/ 1/20

alendronate tab

5mg


Deletion

Please consult with

your doctor.

5/ 1/20

AUGMENTIN

SUS 125/5ML


Deletion

Please consult with

your doctor.

4/ 1/20

AVONEX KIT

30MCG


Deletion

Please consult with

your doctor.

1/ 1/20

AZELEX CRE

20%


Deletion

Please consult with

your doctor.

2/ 1/20

BACTROBAN

OIN NASAL 2%


Deletion

Please consult with

your doctor.

2/ 1/20

BIVIGAM SOL

10GM/100ML


Deletion

Please consult with

your doctor.

1/ 1/20

BRAFTOVI CAP

50MG


Deletion

Please consult with

your doctor.

1/ 1/20

CARAFATE SUS

1GM/10ML


Only generic is

covered.

sucralfate sus

1gm/10ml

2 3/ 1/20

chlorothiazide tab

250mg


Deletion

Please consult with

your doctor.

5/ 1/20

chlorothiazide tab

500mg


Deletion

Please consult with

your doctor.

5/ 1/20

ciprofloxacin sus

500mg/5ml


Deletion

Please consult with

your doctor.

3/ 1/20



Deletions

Affected Drug

Description

of Change

Reason for Change


ciprofloxacin tab

1000mg er


Deletion

Please consult with

your doctor.

1/ 1/20

ciprofloxacin tab

500mg er


Deletion

Please consult with

your doctor.

1/ 1/20

colocort ene

100mg


Deletion

Please consult with

your doctor.

4/ 1/20

CORDRAN 80X3

TAP 4MCG/CM


Deletion

Please consult with

your doctor.

2/ 1/20

d5w/nacl inj

0.33%


Deletion

Please consult with

your doctor.

2/ 1/20

DAKLINZA TAB

30MG


Deletion

Please consult with

your doctor.

1/ 1/20

DAKLINZA TAB

60MG


Deletion

Please consult with

your doctor.

1/ 1/20

DARAPRIM TAB

25MG


Only generic is

covered.

pyrimethamine tab

25mg

5 PA 7/ 1/20

delyla tab

0.1-0.02mg


Deletion

Please consult with

your doctor.

2/ 1/20

DEPEN

TITRATABS


Only generic is

covered.

penicillamin tab

250mg

5 4/ 1/20

eprosartan mes

tab 600mg


Deletion

Please consult with

your doctor.

6/ 1/20

ESBRIET TAB

267MG


Deletion

Please consult with

your doctor.

3/ 1/20

EURAX CRE 10% Deletion CMS Mandated

Deletion

Please consult with

your doctor.

4/ 1/20

FARYDAK CAP

15MG


Deletion

Please consult with

your doctor.

5/ 1/20

fenofibric tab

105mg


Deletion

Please consult with

your doctor.

4/ 1/20

fenofibric tab

35mg


Deletion

Please consult with

your doctor.

4/ 1/20

FENTORA TABS

100MCG


Deletion

Please consult with

your doctor.

1/ 1/20



Deletions

Affected Drug

Description

of Change

Reason for Change


FENTORA TABS

200MCG


Deletion

Please consult with

your doctor.

1/ 1/20

FENTORA TABS

400MCG


Deletion

Please consult with

your doctor.

1/ 1/20

FENTORA TABS

600MCG


Deletion

Please consult with

your doctor.

1/ 1/20

FENTORA TABS

800MCG


Deletion

Please consult with

your doctor.

1/ 1/20

FIRAZYR SOL

30MG/3ML


Deletion

Please consult with

your doctor.

1/ 1/20

FIRVANQ SOL

50MG/ML


Only generic is

covered.

vancomycin sol 50

mg/ml

2 2/ 1/20

flurbiprofen tab

50mg


Deletion

Please consult with

your doctor.

5/ 1/20

gavilyte-g sol

236g-2.97g-6.74g-

5.86g-22.74g


Deletion

Please consult with

your doctor.

2/ 1/20

HUMIRA PEDIA

INJ CROHNS

40MG/0.8ML 3

COUNT


Deletion

Please consult with

your doctor.

4/ 1/20

HUMIRA PEDIA

INJ CROHNS

40MG/0.8ML 6

COUNT


Deletion

Please consult with

your doctor.

4/ 1/20

hydromorphone

hcl 2mg/ml


Deletion

Please consult with

your doctor.

5/ 1/20

ISORDIL

TITRADOSE TAB

40MG


Only generic is

covered.

isosorbide dinitrate

tab 40mg

5 3/ 1/20

isosorbide

dinitrate tab

40mg er


Deletion

Please consult with

your doctor.

3/ 1/20

jolivette tab

0.35mg


Deletion

Please consult with

your doctor.

1/ 1/20

kcl/d5w/nacl inj Deletion CMS Mandated

Deletion

Please consult with

your doctor.

2/ 1/20



Deletions

Affected Drug

Description

of Change

Reason for Change


klor-con spr cap

8meq


Deletion

Please consult with

your doctor.

4/ 1/20

LAZANDA SPR

100MCG


Deletion

Please consult with

your doctor.

7/ 1/20

LAZANDA SPR

300MCG


Deletion

Please consult with

your doctor.

7/ 1/20

LAZANDA SPR

400MCG


Deletion

Please consult with

your doctor.

7/ 1/20

LYRICA CAP

100MG


Deletion

Please consult with

your doctor.

1/ 1/20

LYRICA CAP

150MG


Deletion

Please consult with

your doctor.

1/ 1/20

LYRICA CAP

200MG


Deletion

Please consult with

your doctor.

1/ 1/20

LYRICA CAP

225MG


Deletion

Please consult with

your doctor.

1/ 1/20

LYRICA CAP

25MG


Deletion

Please consult with

your doctor.

1/ 1/20

LYRICA CAP

300MG


Deletion

Please consult with

your doctor.

1/ 1/20

LYRICA CAP

50MG


Deletion

Please consult with

your doctor.

1/ 1/20

LYRICA CAP

75MG


Deletion

Please consult with

your doctor.

1/ 1/20

LYRICA SOL

20MG/ML


Deletion

Please consult with

your doctor.

1/ 1/20

MAXIPIME INJ

2GM


Deletion

Please consult with

your doctor.

3/ 1/20

metadate tab

20mg er


Deletion

Please consult with

your doctor.

7/ 1/20

methyclothiazide

tab 5mg


Deletion

Please consult with

your doctor.

2/ 1/20

mimvey lo tab

0.5mg-0.1mg


Deletion

Please consult with

your doctor.

2/ 1/20

mononessa tab

35mcg-0.25mg


Deletion

Please consult with

your doctor.

1/ 1/20



Deletions

Affected Drug

Description

of Change

Reason for Change


morgidox cap

1x50mg


Deletion

Please consult with

your doctor.

2/ 1/20

morphine sul inj

10mg/ml


Deletion

Please consult with

your doctor.

2/ 1/20

morphine sul inj

2mg/ml


Deletion

Please consult with

your doctor.

1/ 1/20

morphine sul inj

4mg/ml


Deletion

Please consult with

your doctor.

1/ 1/20

morphine sul inj

5mg/ml


Deletion

Please consult with

your doctor.

1/ 1/20

nadolol/bendroflu

methiazide tab

40-5mg


Deletion

Please consult with

your doctor.

2/ 1/20

NEBUPENT INJ

300MG


Only generic is

covered.

pentamidine inh

300mg

2 PA 3/ 1/20

NEXIUM PACK

10MG


Only generic is

covered.

esomeprazole gra

10mg dr

2 QL 6/ 1/20

NEXIUM PACK

20MG


Only generic is

covered.

esomeprazole gra

20mg dr

2 QL 6/ 1/20

NEXIUM PACK

40MG


Only generic is

covered.

esomeprazole gra

40mg dr

2 QL 6/ 1/20

noreth/ethin tab fe

1mg/20mcg


Deletion

Please consult with

your doctor.

4/ 1/20

norlyroc tab

0.35mg


Deletion

Please consult with

your doctor.

2/ 1/20

NOXAFIL TAB

100MG


Only generic is

covered.

posaconazole tab dr

100 mg

5 2/ 1/20

peg 3350 sol

electrolytes


Deletion

Please consult with

your doctor.

4/ 1/20

PENTAM 300 INJ Deletion Available in generic.

Only generic is

covered.

pentamidine inj

300mg

2 3/ 1/20



Deletions

Affected Drug

Description

of Change

Reason for Change


premasol sol 6% Deletion CMS Mandated

Deletion

Please consult with

your doctor.

4/ 1/20

PROGLYCEM

50MG/ML


Only generic is

covered.

diazoxide sus

50mg/ml

5 7/ 1/20

promethazine sup

50mg


Deletion

Please consult with

your doctor.

2/ 1/20

ranitidine hcl syrp

75mg/5ml


Deletion

Please consult with

your doctor.

6/ 1/20

ranitidine hcl tab

300mg


Deletion

Please consult with

your doctor.

6/ 1/20

ranitidine

hydrochloride cap

150mg


Deletion

Please consult with

your doctor.

6/ 1/20

ranitidine

hydrochloride cap

300mg


Deletion

Please consult with

your doctor.

6/ 1/20

ranitidine

hydrochloride tab

150mg


Deletion

Please consult with

your doctor.

6/ 1/20

REBETOL SOL

40MG/ML


Deletion

Please consult with

your doctor.

2/ 1/20

RESCRIPTOR

TAB 200MG


Deletion

Please consult with

your doctor.

6/ 1/20

REVATIO SUS

10MG/ML


Deletion

Please consult with

your doctor.

1/ 1/20

RIBAPAK PAK

1200MG/DAY


Deletion

Please consult with

your doctor.

2/ 1/20

RIBAPAK TAB

1000MG/DAY


Deletion

Please consult with

your doctor.

2/ 1/20

ribasphere cap

200mg


Deletion

Please consult with

your doctor.

2/ 1/20

RIBASPHERE

TAB 600MG


Deletion

Please consult with

your doctor.

2/ 1/20

SILENOR TAB

3MG


Only generic is

covered.

doxepin tab 3mg 2 3/ 1/20



Deletions

Affected Drug

Description

of Change

Reason for Change


SILENOR TAB

6MG


Only generic is

covered.

doxepin tab 6mg 2 3/ 1/20

sod lactate inj

5meq/ml


Deletion

Please consult with

your doctor.

4/ 1/20

soloxide tab

150mg dr


Deletion

Please consult with

your doctor.

2/ 1/20

SYLATRON KIT

600MCG


Deletion

Please consult with

your doctor.

4/ 1/20

TARCEVA TAB

100MG


Deletion

Please consult with

your doctor.

1/ 1/20

TARCEVA TAB

150MG


Deletion

Please consult with

your doctor.

1/ 1/20

TARCEVA TAB

25MG


Deletion

Please consult with

your doctor.

1/ 1/20

TDVAX Deletion CMS Mandated

Deletion

Please consult with

your doctor.

7/ 1/20

theophylline tab

100mg cr


Deletion

Please consult with

your doctor.

1/ 1/20

theophylline tab

200mg cr


Deletion

Please consult with

your doctor.

1/ 1/20

tolazamide tab

250mg


Deletion

Please consult with

your doctor.

1/ 1/20

tolazamide tab

500mg


Deletion

Please consult with

your doctor.

1/ 1/20

tolbutamide tab

500mg


Deletion

Please consult with

your doctor.

4/ 1/20

TRANSDERM-S

COP

1MG/3DAYS


Deletion

Please consult with

your doctor.

1/ 1/20

TRAVATAN Z

0.004%


Only generic is

covered.

travoprost dro

0.004%

2 3/ 1/20

ULORIC TAB

40MG


Deletion

Please consult with

your doctor.

1/ 1/20

ULORIC TAB

80MG


Deletion

Please consult with

your doctor.

1/ 1/20



Deletions

Affected Drug

Description

of Change

Reason for Change


vicodin tab

300-5mg


Deletion

Please consult with

your doctor.

1/ 1/20

vicodin es

300mg-7.5mg


Deletion

Please consult with

your doctor.

2/ 1/20

vicodin hp tab

10-300mg


Deletion

Please consult with

your doctor.

4/ 1/20

VIDEX EC CAP

125MG


Deletion

Please consult with

your doctor.

7/ 1/20

VIDEX

PEDIATRIC SOL

2GM


Deletion

Please consult with

your doctor.

7/ 1/20

ZORTRESS TAB

0.25MG


Only generic is

covered.

everolimus tab

0.25mg

5 PA 6/ 1/20

ZORTRESS TAB

0.5MG


Only generic is

covered.


ZORTRESS TAB

0.75MG


Only generic is

covered.

everolimus tab

0.75mg

5 PA 6/ 1/20

ZYKADIA CAP

150MG


Deletion

Please consult with

your doctor.

2/ 1/20



Tier Changes

Affected Drug Tier* Notes Effective Date

* Lower cost sharing tier



Requirement Changes

Drug Name Tier Notes EffDate

ezetimibe/simvastatin tab 10-80mg

BALVERSA TAB 3MG

2

5

PA Removal

QL Removal

1/ 1/20

1/ 1/20

BALVERSA TAB 4MG 5 QL Removal 1/ 1/20

BALVERSA TAB 5MG 5 QL Removal 1/ 1/20

simvastatin tab 80mg 1 PA Removal 1/ 1/20

NEXIUM GRA 40MG DR 3 QL Increase: New QL (60 caps

per 30 days)

2/ 1/20


per 30 days)

2/ 1/20


per 30 days)

2/ 1/20


per 30 days)

2/ 1/20

NEXIUM GRA 2.5MG DR 3 QL Increase: New QL (60 caps

per 30 days)

2/ 1/20

rabeprazole tab 20mg 2 QL Increase: New QL (60 caps

per 30 days)

2/ 1/20

esomeprazole mag cap 20mg dr 2 QL Increase: New QL (60 caps

per 30 days)

2/ 1/20



Documents

Formulary Addendum as of July 1, 2020 · ID: 20480 Version: 12 QL=Quantity Limits Apply, ST=Step Therapy Applies, PA=Prior Authorization Applies, LA =Limited Access